Rehabilitation interventions for persons with hip fracture and cognitive impairment: A scoping review

Background Hip fractures are common fall-related injuries, with rehabilitation and recovery often complicated by cognitive impairment. Understanding what interventions exist, and in what settings, for people with hip fracture and co-occurring cognitive impairment is important in order to provide more evidence on rehabilitation and related outcomes for this population. Objective To examine the extent, nature, and range of literature on rehabilitation interventions for adults with hip fracture and cognitive impairment. Methods Articles were required to: include an adult population with hip fracture and cognitive impairment, include a rehabilitation intervention, and be published between January 1, 2000 and November 19, 2021. Articles were excluded if they were opinion pieces, study protocols, conference abstracts, or if they did not describe the rehabilitation intervention. Relevant articles were searched on the following electronic databases: MEDLINE, EMBASE, CINAHL Plus, APA PsycINFO, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database. All articles were double-screened by two reviewers and disagreements were resolved through consensus. Data were extracted and synthesized using descriptive approaches. Results Seventeen articles were included in this scoping review. We identified a variety of interventions targeting this population; about half were specific to physical rehabilitation, with the other half incorporating components that addressed multiple aspects of the care journey. Interventions had varying outcomes and no studies qualitatively explored patient or family experiences. All intervations were initiated in hospital, with less than half including cross-sectoral components. About half of the articles described modifying or tailoring the intervention to the participants’ needs, but there was limited information on how to adapt rehabilitation interventions for individuals with cognitive impairment. Conclusions More work is need to better understand patient, family, and provider experiences with rehabilitation interventions, how to tailor interventions for those with cognitive impairment, and how to successfully implement sustainable interventions across sectors.

In this context, it is important to better understand what interventions currently exist and in what settings for people with hip fracture and co-occurring cognitive impairment in order to provide more evidence on rehabilitation and related outcomes for this population. To our knowledge, two similar systematic reviews have been conducted [28,29]; however, there are limitations to these reviews that our scoping review aims to address. First, both reviews focused on specific healthcare sectors, such as community-based interventions [29], long-term care [28], and post-acute rehabilitation settings [28]. As current guidelines recommend mobilization within 24 to 48 hours post-surgery [20][21][22], it is important to examine interventions offered in acute care, as well as across the continuum of care (including post hospital care in the community). Secondly, the previous reviews limited their populations to older adults (�65 years old). While older age is a risk factor for both hip fractures and cognitive impairment [30,31], they can occur at earlier ages as well [32,33].
The objective of this scoping review was to examine the extent, nature, and range of literature on rehabilitation interventions for adults (aged 18+) with hip fracture and cognitive impairment. A scoping review methodology was appropriate for addressing this goal as it allowed us to identify a broader range of literature available on this topic, examine characteristics pertaining to interventions for persons with hip fracture and cognitive impairment, address current gaps in the literature, and highlight areas that warrant future work.

Methods
This scoping review was conducted based on the most recent methodology outlined by Peters and colleagues [34]. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review (PRISMA-ScR) was also followed (see S1 Table) [35].

Protocol and registration
A protocol for this scoping review was registered on Open Science Framework (10.17605/OSF. IO/ZA92V).

Eligibility criteria
The inclusion criteria for this scoping review were as follows: (1) included adults with hip fracture and cognitive impairment, (2) included a rehabilitation intervention that focused on at least physical functioning, and (3) published from January 1, 2000 to November 19, 2021. We only included articles published as of 2000 to ensure healthcare relevancy. Articles were excluded if they met any of the following criteria: (4) opinion pieces (e.g. editorial, commentary), (5) study protocols, (6) did not describe the rehabilitation intervention, or (7) conference abstracts.

Information sources
Databases were selected based on their topic concentrations in order to ensure maximum recall of relevant studies [36]. The following electronic databases were searched on November 19, 2021: MEDLINE (Ovid Interface), EMBASE (Ovid Interface), CINAHL Plus (EBSCOhost Interface), APA PsycINFO (Ovid Interface), Cochrane Library, and Web of Science. The Physiotherapy Evidence Database (PEDro) was also searched for relevant randomized controlled trials, systematic reviews, and clinical practice guidelines. Using the final included articles, Web of Science was used to conduct forward and backward searching [37] on January 14, 2022.

Search strategy
The original search strategy was developed by the research team. The search strategy underwent a peer review by a librarian using the Peer Review of Electronic Search Strategies (PRESS) checklist [38] and minor revisions were made (see S2 Table for the Medline search strategy). The search strategy used medical subject headings and keywords to combine three main concepts: hip fracture, cognitive impairment, and intervention. The search strategy was manually adapted for each database.

Selection process
All articles from the database searches were imported into EndNote X8, and duplicates were removed following Bramer's method for de-duplication [39]. Following de-duplication, articles were imported into Covidence for article screening. The titles and abstracts of 25 articles were screened by two reviewers (SJTG and LC) to test their agreement. The screeners had an agreement of 96%, so they proceeded with screening the remainder of the titles and abstracts. All articles were double screened and any disagreements were resolved through consensus. After the completion of the title and abstract screening, the same two reviewers (SJTG and LC) screened 15 full-texts to test their agreement. The screeners had an agreement of 93%, so they proceeded with screening the remainder of the full-text articles. All full-texts were double screened and disagreements were resolved through consensus.

Data charting process
A study-specific, data extraction form was developed in Microsoft Excel to facilitate the consistent extraction of information. Two team members (SJTG and LC) tested the extraction form and completed a spot check of 10% of the articles to ensure the information extracted was complete, accurate, and consistent. Minor/no revisions were made to the data extraction form during this process.

Data items
Data were extracted on general information (title, authors, journal, year of publication, funding), study characteristics (objective, research question, hypotheses, type of population, method of data collection, study design, theoretical orientation, eligibility criteria, primary and secondary outcomes, country, setting), rehabilitation intervention characteristics (description, content, frequency, duration, single or multi-component, format, modifications, tailoring, delivery, setting), population characteristics (sample size, age, sex, gender, ethnicity/race, income, education, marital status, household composition, employment status, reason for hospitalization, type/severity of cognitive impairment, comorbidities, residence pre-hospitalization), study outcomes and findings (results and key findings, conclusions), and qualitative findings, if applicable (themes, conceptualization of themes). The Template for Intervention Description and Replication (TIDieR) checklist was used to guide the data items extracted for rehabilitation intervention characteristics [40].

Synthesis methods
Data were synthesized using descriptive approaches. We summarized the study types, years of publication, countries, populations, types of rehabilitation interventions, and outcomes of the interventions. We used content from the TIDieR checklist to guide the presentation of the results [40]. A critical appraisal of articles was not conducted, but is not a requirement for scoping reviews [35].

Population characteristics
The majority of studies focused on and included older adults (defined as 60, 65, or 70 years and older) [41-48, 50, 52, 54-57] and all but one study [49] had participants with a mean age of 75 years or older. Six articles included only participants with cognitive impairment and hip fracture [41,42,47,50,53,57], while the remaining 11 articles included both those with and  Table 2 displays the intervention characteristics of the included articles. About half of the interventions (n = 8) were specific to physical rehabilitation [41-43, 47, 50-53], while the other half (n = 9) incorporated content into the intervention that addressed additional aspects of the patients' care journey or support (e.g. discharge planning, patient and family education, nutrition) [44-46, 48, 49, 54-57]. The physical rehabilitation component of the interventions most commonly incorporated standing, walking with or without support, range of motion, balance exercises, and functional strength. As measured by the primary or secondary outcomes, the focus of the majority of interventions was to improve participants' physical functioning (walking ability) and ability to perform activities of daily living [41, 42, 44-48, 50-52, 54, 56, 57]. Other outcomes assessed less frequently were mortality [42,43,46,50,53,54,56], length of stay [43][44][45][46]56], readmissions [45,46,54,56], and quality of life [42,57]. The experiences of patients and families were not qualitatively explored in any of the included articles. The interventions were most commonly delivered by an interdisciplinary team consisting of a combination of the following: physiotherapists, occupational therapists, nurses, social workers, physicians and/or geriatricians. Of the two interventions that were delivered by a single profession, physiotherapists were responsible [42,50]. About half of the articles (n = 9) described modifying or tailoring the intervention to the individuals' needs [42-46, 49, 52, 54, 55]. This was usually dependent on how the patient was progressing with their physical rehabilitation [43-46, 52, 54]; however, one article described modifications or adaptations that were made for individuals depending on their level of cognitive impairment [42]. All interventions were initiated face-to-face in hospital (in acute care or inpatient rehabilitation) and six included cross-sectoral components [44-46, 54, 55, 57] in the form of in-home rehabilitation [44-46, 54, 55, 57], in-home training for families [57], community and long-term care assessments, referrals, or initiation of services [54,55,57], and telephone follow-ups [54,55]. There was wide variation in the length, frequency, and duration of the interventions. The length of physical rehabilitation sessions varied from 20 minutes to 60 minutes, the frequency varied from multiple sessions daily to a few sessions per week, and the duration was not consistently reported (some were only delivered until discharge from hospital, while others included follow-up in the community). Most articles described starting physical rehabilitation one day post-surgery.

Intervention outcomes
The outcomes of the interventions varied across the included articles. Improved walking ability was identified in four articles [41,42,44,56]; however no differences were noted in three articles [44,46,48]. Preserved or improved performance of activities of daily living (e.g. mobility, bathing, dressing, toileting and continence, transferring, feeding) was identified in four     articles [41,47,54,56], with no differences found in two [45,46]. Length of hospital stay or rehabilitation time was shorter for the intervention group, compared to the control group in five articles [43,44,46,51,56]. Lower rates of mortality in intervention groups compared to the control were found in two articles [50,53], with no differences identified in three articles [43,46,56]. Four of the included articles compared outcomes between those with hip fracture and cognitive impairment and those without cognitive impairment [43,46,52,54]. Three of the four studies found comparable outcomes between the groups [43,46,52]; activities of daily living and walking ability were comparable regardless of cognitive status [46], functional gain was not associated with cognitive status [52], and the ability to return to independent living was comparable between patients with mild cognitive impairment and those with normal cognitive function [43]. The article that found differences noted that patients with cognitive impairment in the rehabilitation group did not experience improvements in subsequent falls (fewer falls) or emergency room visits, as those without cognitive impairment experienced [54]. Patients with cognitive impairment (in the control group) also had poorer outcomes with walking ability and activities of daily living performance when compared to those without cognitive impairment (in the control group) [54].

Discussion
The purpose of this scoping review was to identify rehabilitation interventions for adults with hip fracture and cognitive impairment, while not limiting by sector of implementation or age of the population. Based on the 17 included articles, we found that (1) several forms of rehabilitation interventions were available, with varying outcome measures and success; however, none of the included studies explored patient and family experiences; (2) information on how to adapt rehabilitation interventions for individuals with cognitive impairment was lacking; and (3) few interventions were implemented across sectors. Sixteen of the 17 included articles were quantitative and most commonly assessed participants' physical functioning (walking ability), ability to perform activities of daily living, mortality, length of stay, readmission rates, and quality of life. Despite varying results across these outcomes, we identified some evidence to suggest that patients with cognitive impairment should not be excluded from rehabilitation. For example, improvements were identified in walking ability, activities of daily living, length of stay, and physical functioning, and in some cases, the improvements were comparable to those seen in individuals without cognitive impairment. This echoes findings from previous research [28,29,58], including two systematic reviews in which benefits of rehabilitation interventions for older adults with hip fracture and cognitive impairment were reported [28,29], as well as noting that participants did not experience harm (e.g., falls, exacerbation of previous medical issues) when taking part in rehabilitation activities [28]. Further to these reviews, a qualitative study conducted by Sondell and colleagues described the benefits of a multidimensional and interdisciplinary rehabilitation program for older adults with dementia, which included: improved physical abilities, motivation and self-efficacy, feelings of empowerment, the ability to participate in everyday activities, an increased sense of responsibility to continue exercise post-rehabilitation, and the creation of friendships [58]. The study by Sondell et al. provided important contextual information on how the participants experienced the multidimensional interdisciplinary rehabilitation in dementia program, which is currently missing for adults with hip fracture and cognitive impairment. This presents a critical area for future research to explore, in order to better understand the experiences, perceptions, and reflections of those with lived experience pertaining to current rehabilitation interventions. This scoping review also identified the need to better understand how to modify and tailor interventions for individuals' needs, especially how to adapt interventions for those with differing levels of cognitive impairment. Only one of the included articles explicitly reported adapting the intervention based on individuals' cognitive impairment; however, the process for doing so was not described. This finding is similar to that of Chu and colleagues, who described the need for an increased focus on rehabilitation interventions that are tailored, or potentially newly developed, for patients with cognitive impairment [29].
Opportunities to better understand how to tailor rehabilitation interventions to those with hip fracture and cognitive impairment can be explored through qualitative research and codesign. Qualitatively exploring the perspectives and experiences of patients, caregivers, providers, and organizational leaders can serve as a foundational starting point for better understanding patient and family needs during rehabilitation post-hip fracture. Based on their experiences, individuals can provide valuable insights into what is working well, what can be improved, as well as new ideas for tailoring programs for those with cognitive impairment. Additionally, rehabilitation interventions would benefit from being co-designed in collaboration between patients, families, and providers. Since none of the included articles explored patient and caregiver experiences with the interventions, co-design allows for the integration of these perspectives. Co-design includes the meaningful involvement of stakeholders during the planning, design, implementation, and adaptation of the intervention in order to meet the needs and preferences of its users [59]. Despite not having a standardized process, core principles of co-design include: equality, openness, respect, empathy, understanding, and improvement [60,61]. Importantly, co-design offers a number of benefits for all stakeholders such as increased buy-in, enhanced understanding of goals and objectives, and improved experiences [59][60][61].
All of the interventions were initiated in-hospital, in acute care or inpatient rehabilitation, with only six including cross-sectoral components. Following a hip fracture, patients frequently experience numerous transitions across different settings and healthcare providers [62,63]. Transitions in care have been identified as a vulnerable time for patients and families, often characterized as fragmented and resulting in poor health outcomes, including deconditioning, decreased satisfaction, high readmission rates, increased adverse events, and unmet needs [64,65]. Despite the potential for poor health and social outcomes during care transitions, we found that only half of the articles included in this review incorporated components into the intervention that extended beyond physical rehabilitation to address rehabilitation more holistically (discharge planning, nutrition, and patient and family education). The connection between physical health, mental health, and social health has been well-documented [66,67], but the integration of the three into rehabilitation interventions for adults with hip fracture and cognitive impairment is lacking. Based on the potential negative consequences that can occur during care transitions, rehabilitation interventions should be multidimensional, addressing physical, mental, and social health, and include cross-sectoral components to ensure continuity along the continuum of care (hospital, primary care, rehabilitation, home and community care) for adults with cognitive impairment following a hip fracture.

Gaps and opportunities for future research
This scoping review identified several gaps in the literature that warrant additional research. First, patient, family, and provider experiences and perspectives should be explored during the development, implementation, and evaluation of interventions for persons with cognitive impairment and hip fracture. Second, rehabilitation interventions should be co-designed with patients and families to ensure their insights and experiences can be used to inform programs and practiced-based decisions. Lastly, based on the interconnectedness of physical, mental, and social well-being [66,67], there is a need to incorporate components into rehabilitation interventions that extend beyond improving physical functioning (i.e., social aspects, mental health, education for patients and families) and are implemented across sectors.

Strengths and limitations
A few notable strengths of this scoping review are working in collaboration with a librarian to develop a comprehensive search strategy, undergoing a peer review of the search strategy, and supplementing the search with forward and backward searching. Additionally, we used a rigorous double-screening process to ensure two individuals independently screened all potential articles. Despite these strengths, it is possible that some relevant articles were missed due to only searching literature published from 2000 onwards and our search being in English.

Conclusions
This scoping review identified a number of rehabilitation interventions for adults with hip fracture and cognitive impairment. The majority of included studies were quantitative, with a lack of exploration of patient and family experiences. Interventions had varying outcomes, but there were some positive results, highlights the need for providing post-hip fracture rehabilitation to adults with cognitive impairment. All interventions were initiated in hospital, with few including cross-sectoral components. Future work should focus on exploring patient, family, and provider experiences with rehabilitation interventions, tailoring interventions for those with cognitive impairment, and implementing interventions across sectors.
Supporting information S1